<jsp:include page="template_header.jsp" />

            <div class="span9"> <!-- /write your content -->
                <div class="page-header">
                    <h3>Create Customer Account</h3>
                </div>    
                <jsp:include page="error-list.jsp" />
                <form id="createCusAccountForm" class="form-horizontal" method="post">            	
                	<div class="control-group">
					    <label class="control-label" for="firstname">First Name</label>
					    <div class="controls">
					      <input type="text" id="firstname" name="firstName" value="${form.firstName }"/>
					    </div>
					</div>

					<div class="control-group">
					    <label class="control-label" for="lastname">Last Name</label>
					    <div class="controls">
					      <input type="text" id="lastname" name="lastName" value="${form.lastName }"/>
					    </div>
					</div>


                	<div class="control-group">
					    <label class="control-label" for="username">User Name</label>
					    <div class="controls">
					      <input type="text" id="username" name="userName" value="${form.userName }"/> 
					    </div>
					</div>	

					<div class="control-group">
					    <label class="control-label" for="pass">Password</label>
					    <div class="controls">
					      <input type="password" id="pass" name="password" />
					    </div>
					</div>
					
					<div class="control-group">
					    <label class="control-label" for="pass_verify">Verify Password</label>
					    <div class="controls">
					      <input type="password" id="pass_verify" name="confirm" />
					    </div>
					</div>

					<div class="control-group">
					    <label class="control-label" for="addr_line1">Address Line #1</label>
					    <div class="controls">
					      <input type="text" id="addr_line1" name="address1" value="${form.address1}"/>
					    </div>
					</div>

					<div class="control-group">
					    <label class="control-label" for="addr_line2">Address Line #2</label>
					    <div class="controls">
					      <input type="text" id="addr_line2" name="address2" value="${form.address2}"/>
					    </div>
					</div>

					<div class="control-group">

					    <label class="control-label" for="city">City</label>
					    <div class="controls">
					      <input type="text" id="city" name="city" value="${form.city}"/>
					    </div>
					</div>

          			<div class="control-group">
            			<label class="control-label" for="select02">State</label>
            			<div class="controls">
              				<select name="state" id="select02">
                				<option value="AL">Alabama</option>
								<option value="AK">Alaska</option>
								<option value="AZ">Arizona</option>
								<option value="AR">Arkansas</option>
								<option value="CA">California</option>
								<option value="CO">Colorado</option>
								<option value="CT">Connecticut</option>
								<option value="DE">Delaware</option>
								<option value="DC">District of Columbia</option>
								<option value="FL">Florida</option>
								<option value="GA">Georgia</option>
								<option value="HI">Hawaii</option>
								<option value="ID">Idaho</option>
								<option value="IL">Illinois</option>
								<option value="IN">Indiana</option>
								<option value="IA">Iowa</option>
								<option value="KS">Kansas</option>
								<option value="KY">Kentucky</option>
								<option value="LA">Louisiana</option>
								<option value="ME">Maine</option>
								<option value="MD">Maryland</option>
								<option value="MA">Massachusetts</option>
								<option value="MI">Michigan</option>
								<option value="MN">Minnesota</option>
								<option value="MS">Mississippi</option>
								<option value="MO">Missouri</option>
								<option value="MT">Montana</option>
								<option value="NE">Nebraska</option>
								<option value="NV">Nevada</option>
								<option value="NH">New Hampshire</option>
								<option value="NJ">New Jersey</option>
								<option value="NM">New Mexico</option>
								<option value="NY">New York</option>
								<option value="NC">North Carolina</option>
								<option value="ND">North Dakota</option>
								<option value="OH">Ohio</option>
								<option value="OK">Oklahoma</option>
								<option value="OR">Oregon</option>
								<option value="PA">Pennsylvania</option>
								<option value="RI">Rhode Island</option>
								<option value="SC">South Carolina</option>
								<option value="SD">South Dakota</option>
								<option value="TN">Tennessee</option>
								<option value="TX">Texas</option>
								<option value="UT">Utah</option>
								<option value="VT">Vermont</option>
								<option value="VA">Virginia</option>
								<option value="WA">Washington</option>
								<option value="WV">West Virginia</option>
								<option value="WI">Wisconsin</option>
								<option value="WY">Wyoming</option>
              				</select>
            			</div>
          			</div>

          			<div class="control-group">
					    <label class="control-label" for="zip">Zip Code</label>			    
					    <div class="controls">
					      <input type="text" id="zip" name="zipCode" value="${form.zipCode}"/>
					      <p class="help-block"> Eg: 15213 </p>
					    </div>
					</div>

					<div class="control-group">
					    <label class="control-label" for="phNo">Phone No.</label>
					    <div class="controls">
					      <input type="text" id="phNo" name="phoneNo" value="${form.phoneNo}"/>
					      <p class="help-block"> Please enter a valid US phone number. (Eg: 412 666 8888)</p>
					    </div>
					</div>
					<div class="control-group">
					    <label class="control-label" for="cash">Cash Amount</label>
					    <div style="padding-left: 20px;" class="input-prepend input-append">
							 <span class="add-on">$</span>
							 <input class="input" id="cash" type="text" style="width: 180px;" name="cashAmount" value="${form.cashAmount}"/>
							 <p class="help-block"> The cash amount should track to two decimal places. Eg: 300.35 </p>						
						</div>
					</div>						
					<div>
						<div class="controls">
							<button type="submit" class="btn" onclick="hashPasswords()"> Create Account </button>
							<script src="js/md5.js"></script>
							<script>
								function hashPasswords()
								{
									var password = $('#pass_verify').val();
									if(password!="")
									{
										$('#pass_verify').val(md5(password));
									}
									password = $('#pass').val();
									if(password!="")
									{
										$('#pass').val(md5(password));
									}
								}
							</script>				
						</div>
					</div>		
                </form>
            </div> <!-- /end your content-->
		<jsp:include page="template_tail.jsp" />